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<br />Lincoln County <br />M-1978-078-SG <br />George Ansley Pit <br />May 24, 2004 <br />RECE~~E® <br />PERMTI'TEE NAME: <br />PERMff NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br /> <br />MAY 0 3 2004 <br />Division of Minerals & ~Geota9V <br />$281.00 (Due on or before your anniversary date) <br />Lincoln <br />According to C.R.S. 34-32.5-116 or C.R.S. 34-32-116, each year, on the anniversary date of the permit, an <br />operator shall submit the annual fee, a report and map showing the extent of current disturbances to affected <br />_ land, reclamation_accomplished to date and during the preceding yeaz, new disturbances that are anticipated to <br />occur during the upcoming yeaz, reclamation that will be performed during the coming year, the dates for the <br />beginning of active operations, and the date active operations ceased for the year, if any. <br />Please attach ym~r revised written anmral report and anneal re on rt m,~ to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may suffice for a written <br />report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Don Blake <br />Permittee Name: Lincoln County <br />Address: P. O. Box 39 <br />Phone Number: <br />Fax Number: <br />Hugo, CO 80821 <br />(719)743-2337 <br />(719)743-2815 <br />If you have additional comments and/or information that should be provided to the Division, please provide it <br />below or attach it to this form along with your written report and map. Annual Report instructions are <br />enclosed. <br />~~~ <br />Signature of Corpora/te Officer, Owner, or Designee <br />O ~ I r~'~ l0 ~f- <br />Date <br />M:~PERMI7IMAS"lERDOCUMENTSU4-AF-04 <br />